Revista Espa?ola de Artroscopia y Cirugía Articular最新文献

The surgical management of acute acromioclavicular instability is a common procedure within the pathology of the shoulder. In accordance with the Rockwood classification, an assessment should be made of the presence of a horizontal instability component besides the vertical instability. The treatment of acute acromioclavicular dislocations must be adapted to the demands of the patient. The low grade instabilities (types I and II) are treated conservatively. Those considered high grade (types IV-VI) should be treated surgically within 2-3 weeks from the injury. There is still debate on those of type III. The non-surgical treatment of type III injuries provides functional results at least similar to be able to start professional and sports activities. Among the surgical treatments used are found, open surgery procedures using Kirschner wires, polydioxanone pins, or other types of non-absorbable sutures, or hook plates. Arthroscopic techniques use new implants designed to align and reduce the coracoclavicular space. The advantage of arthroscopy is to be able to review and treat associated lesions in the glenohumeral in the same surgical operation.

Acromioclavicular joint disease is a common source of shoulder pain. Post-traumatic sequelae are the most frequent conditions in young patients, although the incidence of distal clavicular osteolysis is increasing. Overuse of the joint and repeated micro-trauma produce subchondral fractures and subsequent osteolysis. The diagnosis is clinical, with compatible imaging studies and a positive response to an anaesthetic injection into the joint. The majority of patients respond to conservative management. Arthroscopy is the gold standard technique for resection of the distal portion of the clavicle in refractory cases.

Objective

The addition of mesenchymal stem cells may increase the chance of healing of meniscal lesions in the avascular zone. The objective of this study is to find out if the postoperative application of the stromal vascular fraction (SVF) from adipose tissue can have an effect on vascularization and cell proliferation in the sutured meniscus.

Methods

Four pigs (8 knees) underwent a longitudinal injury of 10 mm in the avascular area of the medial meniscus in both knees. Two months later the injury was repaired on both knees with a simple suture. At the same time 50 g of abdominal fat was removed and 2 cm³ of SVF was purified (in which it was found to contain approximately 1-5 × 10⁶ mesenchymal stem cells). This was injected into one of the knees of each pig 4 h after the surgery (SVF group), using the other knee as the control group. The animals were sacrificed after 15 days. The following histological parameters with hematoxylin-eosin staining were evaluated: degree of healing, neo-vascularization of tissue and the proliferation of fibro-chondrocytes around the lesion and the presence of new chondrocytes.

Results

The healing rate (unhealed / partial healing / healed) for the SVF group was 1/1/2, and was 2-2-0 for control group (non-significant differences). The degree of neo-vascularization was higher in the SVF group (3.25 vs 2). The degree of fibro-chondrocytes proliferation was greater in the SVF group (2.5 vs 1.75). The formation of isogenic chondrocytes was observed in 2 menisci of the SVF group and none in the control group.

Conclusions

The postoperative intra-articular injection of SVF might increase the neovascularization, the proliferation of fibro-chondrocytes and the repopulation of chondrocytes 15 days after the repair of meniscal injury in pigs.

Evidence level

Experimental study.

Clinical relevance

A system for the use of stem cells is presented that might be easier to implement in humans that cell cultures.

Objectives

To determine the plasma levels of neuropeptide substance P (SP) in patients with chronic subacromial pain due to rotator cuff pathology. To evaluate the correlation between pre and postoperative plasma levels of SP, chronic postoperative pain and postoperative stiffness.

Methods

Prospective, controlled, observational study of 60 consecutive patients with rotator cuff pathology undergoing shoulder arthroscopy with interscalene nerve block. An additional 15 patients with instability without cuff pathology were included as control group. Plasma samples were obtained preoperatively, at 2 hours postoperatively, the day after surgery, and 6 weeks later. Visual analog pain scores and range of motion were registered at 6 weeks.

Results

Preoperative plasma SP levels in patients with rotator cuff pathology were significantly greater than those in the instability control group. Plasma SP levels were sharply decreased soon after surgery in both groups. A statistical correlation was obtained between the sharp fall of circulating plasma SP levels, immediately after surgery, and pain with or without stiffness 6 weeks later.

Conclusion

Patients with pain, with or without stiffness, 6 weeks after arthroscopic surgery for rotator cuff pathology, could have altered peripheral and central pain processing pathways, as suggested by the differences in circulating plasma SP levels observed.

Level of evidence

2A. Non-randomized prospective study.

Clinical relevance

Measurement of neuropeptide SP in the clinical setting has the potential of being used as a prognostic aid to guide individual patient treatment or even to be used as a surrogate outcome measure in trials.

Arthroscopic repair of rotator cuff disorders is a technically demanding, but successful procedure. The main keys to success are a combination of proper indication, good technique, and an adequate rehabilitation protocol. The tears should be evaluated for reparability, taking into account personal, anatomical, and biological considerations.

The first step in an arthroscopic procedure should be to identify the tear pattern and define the repair strategy. The surgeon should then carefully prepare the rotator cuff footprint and use a repair technique that improves tendon-bone contact. It is essential to obtain a tension-free repair with tendon releases if necessary.

After surgery a protocol designed to protect the healing tendon without causing stiffness is essential.

Objective

To analyze the clinical results of meniscus suture using the all-inside or inside-out technique, in a population associated with occupational safety.

Method

A retrospective study conducted on accident patients with reparable vertical meniscus injuries and subjected to a Sequent^® all-inside or inside-out meniscus suture. The patients were evaluated using the Lysholm and International Knee Documentation Committee (IKDC) scales. A total of 43 meniscus tears were repaired, with a mean follow-up of 19.86 months after the date of the surgery (range 6 months to 46 months). The mean age at the time of the surgery was 27.1 years (range16 years to 49 years). The internal meniscus was sutured in 12 cases (27.9%), in the lateral meniscus in 27 cases (62.7%), and in both menisci in 4 patients (9.3%). A simultaneous ligamentoplasty procedure was required in 14 patients due to an anterior cruciate ligament (ACL) injury.

Results

The unsatisfactory postoperative Lysholm and IKDC scores observed in 3 patients were considered as technique failures. The success rate was 93.0%, while the failure rate of the meniscus suture was 7.0%. No superiority of results was obtained in the patients subjected to a simultaneous ligamentoplasty. The mean score on the Lysholm scale increased from 24.81 in the preoperative period to 91.51 (55-100) in the postoperative period, and an increase from 25.66 to 89.94 (45-100) was observed in the mean IKDC score. No complications were observed as regards the surgical technique.

Conclusions

The meniscus suture using the all-inside and inside-out techniques in a group of working patients showed functional improvements with a safe technique with few complications.

Objective

To determine whether a remplissage procedure in patients with large defects of the humeral head compared to those who undergo arthroscopic Bankart repair for anterior glenohumeral instability decreases the rate of recurrence of instability.

Methods

A retrospective matched cohort study of a group of subjects prospectively evaluated with a minimum follow-up of 4 years. Subjects with large humeral Hill-Sachs defects (> 25% of the humeral head, n = 42) were included. Those in which a remplissage had be performed (n = 14) and matched subjects with similar characteristics and humeral lesions (n = 21) were selected. The following parameters were evaluated: recurrence rate, range of motion, Rowe score, Constant score, and Simple Shoulder Test score (SST).

Results

There were no differences in the characteristics of the two cohorts (age, sex, side, number of previous dislocations or hypermobility). After a minimum follow-up of 4 years (mean = 5.4 years [SD = 1.24 years]) one patient (7.1%) in the remplissage group had a recurrence and 4 patients (19%) in the control group, and one patient had a recurrence of instability (24% showed instability; no significant difference, P = .41). In both groups there were significant improvements in the Rowe, Constant, and SST scores (P < .01), but there were no differences between groups. The residual deficit in external rotation in the remplissage group was 9.29°±16.85°, and in the control group it was 9.62̊ ± 20.0̊ (P > .05).

Conclusion

A remplissage procedure does not affect patient functional outcome or the range of motion. The residual instability rate was 7% in the remplissage group and 24% in the control group.

Evidence level

IIb.

Clinical relevance

The remplissage technique is a safe procedure that might have an effect on the rate of recurrence in patients with anterior shoulder instability and large Hill-Sachs humeral lesions.